N.J. Admin. Code § 10:55-1.5 - Prior authorization for prosthetic and orthotic appliances

(a) This section specifies the services that require prior authorization and the procedures to follow. Prior authorization shall be required for:
1. Any prosthetic appliance (except for preparatory (temporary) upper and lower prostheses) for which the provider's charge is $ 1,000.00 or more;
2. Any orthotic appliance for which the provider's charge is $ 500.00 or more; or
3. Replacement of parts of an appliance when the cost exceeds $ 250, except in an emergency (see (d) below);
i. Prior authorization shall not be required for replacement of parts which involve solely the mechanical aspects of an appliance and for which the charge is $ 250.00 or less.
4. Labor (hourly rate) charges for repair of items or appliances totaling more than $ 250.00 shall be prior authorized by the Medical Assistance Customer Center. (See codes L4200 and L7500 (Repair), at N.J.A.C. 10:55-2.)
i. Total labor (hourly rate) charges for repair of items or appliances, not under warranty, are reimburseable for up to $ 250.00.
5. Any foot and ankle orthotic appliance;
6. Any orthopedic footwear; or
7. Custom molded shoes.
(b) HCPCS procedure codes L3001, L3002, L3003, L3010, L3020, L3030, L3040, L3050, L3060, L3070, L3080, L3090, L3215 through L3222, and L3201 through L3207 shall not require prior authorization when these services are provided for the following diagnosis codes: 343.0 to 343.9; 707.0 to 707.9; 711.0 to 712.9; 715.0 to 722.9; 724.0 to 728.9; 730.0 to 737.9; 754.2 to 754.79; 755.0 to 755.39; 755.6 to 755.69; 756.1 to 756.19; 756.8 to 756.89 or 892.0 to 897.7.
1. All claims for orthotics and shoes shall be subject to a post-payment review process to ensure the appropriate reporting of these diagnosis codes on claims and the validity of the claims. As part of this process, medical record documentation may be requested from providers to validate the claims.
(c) For procedure codes L3001 through L3003, L3010, L3020, L3030, L3040, L3050, L3060, L3070, L3080, and L3090, up to four units of orthotics may be provided by the same provider to the same beneficiary during a 12-month period.
(d) For procedure codes L3201 through L3207, L3215 through L3217, L3219, L3221, and L3222, up to two units may be provided by the same provider to the same beneficiary during a 12-month period.
(e) Exceptions to (b) through (d) above shall be made on a case-by-case basis. Determinations will be made by the Division based on the need for the additional service and the specific emergency situations, which shall be documented by the provider and submitted with form FD-357 to the address in (g) below.
(f) If prior authorization is required, the provider shall not provide those items or services until the authorization is received.
(g) To request prior authorization for prosthetic and orthotic services, the provider shall submit form FD-357 (Request for Prior Authorization for Prosthetic and Orthotic Services), together with a prescription, as specified in 10:55-1.6, to the appropriate Medical Assistance Customer Center (MACC) (see N.J.A.C. 10:49, Appendix-Form #13 for address) or to the Central Office of Medicaid, Office of Provider Relations, Division of Medical Assistance and Health Services, Mail Code #15, PO Box 712, Trenton, New Jersey 08625-0712.
1. Prior authorization for all orthopedic footwear and foot orthotics shall be obtained from the Central Office of Medicaid, Office of Utilization Management, except for all components of orthopedic footwear attached to a bar or brace (including the bar, brace, and/or shoe), which must be obtained from the appropriate MACC.
i. When requesting prior authorization for custom molded shoes, the provider shall submit a FD-357 form together with a copy of the prescription and a cost estimate which shall include a detailed cost breakdown of the basic shoe plus any additional charges for materials and/or services.
2. The fiscal agent will inform the provider that the authorization request approved, denied, or suspended. If approved, the letter to the provider will indicate the authorization number that must be recorded at Item 23B on the CMS-1500 claim form.
(h) The Medical Assistance Customer Center shall grant authorization by telephone when an emergency condition exists, as defined in (h)1 below, and 10:49-6.1.
1. When an orthotic or prosthetic appliance or device becomes non-functional due to mechanical failure and must be repaired immediately for the beneficiary to continue normal functional behavior, the situation shall be considered an emergency. Emergencies include, but are not limited to, mechanical breakdown, fitting problems due to anatomical change, skin breakdown, irritation and/or ulcer, pressure pain, or an ill fitting socket.

Notes

N.J. Admin. Code § 10:55-1.5
Amended by R.1998 d.410, effective 8/3/1998.
See: 30 N.J.R. 512(a), 30 N.J.R. 2919(a).
In (c), updated the address.
Amended by R.2000 d.134, effective 4/3/2000.
See: 31 N.J.R. 3964(a), 32 N.J.R. 1206(a).
In (c)2, changed claim form reference; and in (d)1, substituted a reference to beneficiaries for a reference to recipients.
Amended by R.2004 d.406, effective 11/1/2004.
See: 35 N.J.R. 4417(a), 36 N.J.R. 4963(a).
Substituted references to Medical Assistance Customer Center (MACC) for references to Medicaid District Office (MDO) throughout; in (c), substituted "Office of Utilization Management" for "Office of Medical Affairs and Provider Relations" in the introductory paragraph of 1 and substituted "CMS" for "NCFA" following "Item 23B on the" in 2.
Amended by R.2005 d.312, effective 9/19/2005.
See: 37 N.J.R. 933(a), 37 N.J.R. 3697(a).
Added (b)-(e); recodified former (b)-(c) as (f)-(g); recodified former (d) as (h) and amended introductory paragraph.
Amended by R.2011 d.080, effective 3/7/2011.
See: 42 N.J.R. 2179(a), 43 N.J.R. 622(a).
In (g), deleted ", see Appendix A" following the first occurrence of "Services" and "Medical Affairs and" preceding "Provider", and substituted "13" for "17".

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